Bone marrow aspiration and biopsy: techniques and practice implications

A set of pretreatment reagents including improved formula fixation and decalcification facilitating immunohistochemistry and DNA analyses of formalin-fixed paraffin-embedded bone marrow trephine biopsy

Bone marrow biopsy depends on tissue morphology, immunohistochemical staining, and moleculardetection. Tissue pretreatment is required for bone marrow samples, from clinical specimen acquisition to pathological reporting, but during the process, proteins and nucleic acids are often altered because of the acid in fixation and decalcification solutions. In our study, we present an easy and effective pretreatment protocol and compared this novel pretreatment protocol (Set 2) with an existing traditional pretreatment process (Set 1) using tissue morphology, IHC staining, and molecular pathological analyses. Granulocytic IHC markers showed more intensive staining in samples of Set 2 than in those of Set 1. The Set 2 protocol provided a higher DNA yield and less fragmentation; moreover, samples processed with the Set 2 protocol could be subsequently used in FISH and DNA sequencing assays. Our optimized novel pretreatment protocol could better protect proteins and DNA molecules while maintaining good cell morphology compared to traditional pretreatment The novel pretreatment reagents could role as a reference by more laboratories for pretreating bone marrow biopsy samples and scientific research.

Comparison of Pain and Complications between Outpatients and Inpatients Treated with Bone Marrow Aspirate Concentrate for Knee Osteoarthritis

Bone marrow aspirate concentrate (BMAC) has been increasingly used as an injectable treatment for knee osteoarthritis (OA). However, there remains a lack of studies on the pain and complications associated with BMAC treatment. This study compared the pain and complications of BMAC treatment between outpatients and inpatients with Kellgren-Lawrence grade II-III knee osteoarthritis (OA) during a follow-up period of ≥3 months. This study included 40 outpatients (40 knees) and 80 inpatients (80 knees) as controls who received BMAC articular injections for knee OA between December 2023 and March 2024. Outpatients were administered BMAC under local anesthesia alone, whereas inpatients were administered BMAC under local anesthesia and intravenous anesthesia. The outcomes were the visual analog scale (VAS) pain score during the BMAC procedure and the complications associated with harvest and injection sites. The mean VAS pain score in the outpatient group was significantly higher than that in the inpatient group during trocar insertion (5.2 vs. 1.3, p < 0.05) and bone marrow aspiration (6.2 vs. 1.4, p < 0.05), but it was similar between the two groups during BMAC injection (2.2 vs. 2.3, p = 0.858). Transient post-treatment complications were observed in 17.5% (7/40) of outpatients and 16.3% (13/80) of inpatients. No significant differences were observed in complications between the two groups, all of which were resolved within 2 months without any specific problem. Moreover, no major complications occurred in any group. In conclusion, outpatients who received only local anesthesia reported significant pain during BMAC treatment. The addition of intravenous anesthesia is necessary to alleviate pain during the BMAC procedure.

CT guided versus non-image guided bone marrow aspiration and biopsy: Comparison of indications, specimen quality and cost

PURPOSE

To compare the indications, specimen quality, and cost of CT versus non-image guided bone marrow aspirate and biopsy (BMAB).

METHODS

All CT and non-image guided BMAB performed from January 2013-July 2022 were studied. Body-mass-index (BMI), skin-to-bone distance, aspirate, and core specimen quality, and core sample length were documented. Indications for CT guided BMAB were recorded. Categorical variables were compared using chi-squared test and continuous variables using Mann-Whitney test. Analysis of per-biopsy factors used linear mixed-effect models to adjust for clustering. Cost of CT and non-image guided BMAB was taken from patient billing data.

RESULTS

There were 301 CT and 6535 non-image guided BMABs studied. All CT guided BMAB were studied. A subset of 317 non-image guided BMAB was selected randomly from the top ten CT BMAB referrers. BMI (kg/m2) and skin-to-bone distance (cm) was higher in the CT versus the non-image guided group; 34.4 v 26.8, p < 0.0001; 4.8 v 2.5, p < 0.0001, respectively. Aspirate and core sample quality were not different between groups, p = 0.21 and p = 0.12, respectively. CT guided core marrow samples were longer, p < 0.0001. The most common CT BMAB referral indications were large body habitus (47.7 %), failed attempt (18.8 %) and not stated (17.4 %). Cost of a CT guided BMAB with conscious sedation was $3945 USD versus $310 USD for non-image guided.

CONCLUSION

CT guided BMAB are commonly performed in patients with large body habitus and failed attempt. However, the cost is 12.7 fold higher with no increase in specimen quality. These findings can help referrers be cost conscious.

The effectiveness of non-pharmacological interventions on reducing pain in patients undergoing bone marrow aspiration and biopsy: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Patients often consider bone marrow aspiration and biopsy to be one of the most painful medical procedures. The effectiveness of non-pharmacological interventions to reduce pain during bone marrow aspiration and biopsy remains unclear.

AIM

To synthesize existing evidence regarding the effectiveness of non-pharmacological interventions in mitigating procedural pain among patients undergoing bone marrow aspiration and biopsy.

DESIGN

A systematic review and meta-analysis of randomized controlled trials.

METHODS

Six electronic databases, including PubMed, EMBASE, CINAHL, PsycINFO, Cochrane Library and Web of Science were searched from inception to July 15, 2023. The risk of bias was assessed using the Cochrane Risk of Bias Tool Version 2.0. Meta-analysis was conducted using STATA 16. The certainty of the evidence was assessed by the GRADE approach.

RESULTS

This meta-analysis included 18 studies derived from 17 articles involving a total of 1017 participants. The pooled results revealed statistically significant pain reduction effects using distraction (SMD: -.845, 95% CI: -1.344 to -.346, p < .001), powered bone marrow biopsy system (SMD: -.266, 95% CI: -.529 to -.003, p = .048), and acupoint stimulation (SMD: -1.016, 95% CI: -1.995 to -.037, p = .042) among patients undergoing bone marrow aspiration and biopsy. However, the pooled results on hypnosis (SMD: -1.228, 95% CI: -4.091 to 1.515, p = .368) showed no significant impact on pain reduction. Additionally, the pooled results for distraction did not demonstrate a significant effect on operative anxiety (MD: -2.942, 95% CI: -7.650 to 1.767, p = .221).

CONCLUSIONS

Distraction, powered bone marrow biopsy system and acupoint stimulation are effective in reducing pain among patients undergoing bone marrow aspiration and biopsy.

PATIENT OR PUBLIC CONTRIBUTION

Not applicable.

RELEVANCE TO CLINICAL PRACTICE

This meta-analysis highlights the effectiveness of distraction, powered bone marrow biopsy system and acupoint stimulation for reducing pain in patients undergoing bone marrow biopsy. Healthcare professionals should consider integrating these interventions into pain management practices for these patients.

REGISTRATION

(PROSPERO): CRD42023422854.

Bone Marrow Biopsies: Is CT, Fluoroscopy, or no Imaging Guidance the Most Cost-Effective Strategy?

RATIONALE AND OBJECTIVES

To determine the most cost-effective strategy for pelvic bone marrow biopsies.

MATERIALS AND METHODS

A decision analytic model from the health care system perspective for patients with high clinical concern for multiple myeloma (MM) was used to evaluate the incremental cost-effectiveness of three bone marrow core biopsy techniques: computed tomography (CT) guided, and fluoroscopy guided, no-imaging (landmark-based). Model input data on utilities, costs, and probabilities were obtained from comprehensive literature review and expert opinion. Costs were estimated in 2023 U.S. dollars. Primary effectiveness outcome was quality adjusted life years (QALY). Willingness to pay threshold was $100,000 per QALY gained.

RESULTS

No-imaging based biopsy was the most cost-effective strategy as it had the highest net monetary benefit ($4218) and lowest overall cost ($92.17). Fluoroscopy guided was excluded secondary to extended dominance. CT guided biopsies were less preferred as it had an incremental cost-effectiveness ratio ($334,043) greater than the willingness to pay threshold. Probabilistic sensitivity analysis found non-imaging based biopsy to be the most cost-effective in 100% of simulations and at all willingness to pay thresholds up to $200,000.

CONCLUSION

No-imaging based biopsy appears to be the most cost-effective strategy for bone marrow core biopsy in patients suspected of MM.

CLINICAL RELEVANCE

No imaging guidance is the preferred strategy, although image-guidance may be required for challenging anatomy. CT image interpretation may be helpful for planning biopsies. Establishing a non-imaging guided biopsy service with greater patient anxiety and pain support may be warranted.

Research on product design of FAHP bone marrow aspiration needle

Bone marrow aspiration is a crucial medical procedure to obtain bone marrow samples for diagnosis and treatment. However, traditional bone marrow aspiration needles face several challenges such as operational difficulties, inadequate sample acquisition, and patient discomfort. To address these issues, we aimed to design a bone marrow aspiration needle product by using fuzzy analytic hierarchical process (FAHP). The FAHP method was used to identify key factors in the design of the bone marrow aspiration needle, including technicality, usage, and application characteristics. The importance weights and priorities of each factor were determined through questionnaires and interviews with experts. A new bone marrow aspiration needle product was developed based on the results of the FAHP. The new product design considers the weights and priorities assigned to key factors, resulting in improved convenience during operation and a higher success rate of sample acquisition. This was achieved by optimising the structure and material selection of the needle. This study presents a novel bone marrow puncture needle product that effectively integrates the importance and priority of the key factors. It successfully enhances operational performance and patient experience, thereby offering an innovative solution to improve the success rate and therapeutic effect of bone marrow punctures.

Detection and quantification of JAK2V617F copy number by droplet digital PCR versus real-time PCR

Myeloproliferative neoplasm (MPN) usually has an adverse prognosis, progressing to acute leukemia or splanchnic vein thromboses (SVTs). Therefore, early diagnosis and intervention are significantly important. Clinically, the burden of JAK2V617F is a vital diagnostic basis, which can be detected during the early stage of MPN. Thus, an accurate and rapid detective technique is urgently required. In recent years, real-time quantitative PCR (qPCR) has primarily been applied to detect the copies of JAK2V617F, whereas droplet digital PCR (ddPCR), a novel and promising detective tool, can conduct precise and repeatable quantification of nucleic acid copies without relying on the standard curve. In our study, both qPCR and ddPCR are used to evaluate the mutation burden of JAK2V617F in a series of gradient diluted standards and clinical JAK2V617F-positive MPN patients' bone marrow samples collected, while using next-generation sequencing technology (NGS) as a contrast. With the help of statistical methods, our study concluded that ddPCR had a better performance in accuracy, sensitivity, and stability, especially in a low burden. Regarding the accuracy, ddPCR showed a better linearity (Pearson R2 = 0.9926; P < 0.0001) than qPCR (Pearson R2 = 0.9772; P < 0.0001). What is more, ddPCR showed lower intra-assay and inter-assay CVs and the limit of detection (LOD) for the series of diluted standards than qPCR, demonstrating better stability and lower LOD. In a nutshell, ddPCR is a more promising technique for the detection and quantification of JAK2V617F.

(Smoldering) multiple myeloma: mismatch between tumor load estimated from bone marrow biopsy at iliac crest and tumor load shown by MRI

In multiple myeloma and its precursor stages, precise quantification of tumor load is of high importance for diagnosis, risk assessment, and therapy response evaluation. Both whole-body MRI, which allows to investigate the complete bone marrow of a patient, and bone marrow biopsy, which is commonly used to assess the histologic and genetic status, are relevant methods for tumor load assessment in multiple myeloma. We report on a series of striking mismatches between the plasma cell infiltration estimating the tumor load from unguided biopsies of the bone marrow at the posterior iliac crest and the tumor load assessment from whole-body MRI.

Insights into the epidemiology, risk factors, and clinical outcomes of carbapenem-resistant Acinetobacter baumannii infections in critically ill children

Background and aims

Carbapenem-resistant Acinetobacter baumannii (CRAB) has become a leading cause of nosocomial infections with an increasing impact on critically ill patients, yet there is limited data on contributing factors. This study was aim to evaluate the prevalence and risk factors, and clinical outcomes of CRAB infections among critically ill children in a tertiary university teaching hospital in China.

Methods

From January 2016 to December 2021, all children diagnosed with nosocomial Acinetobacter baumannii (A. baumannii) infections in the pediatric intensive care unit (PICU) were identified through the computerized microbiology laboratory databases. Among them, children suffering from CRAB infection were designated as a case group, while children with carbapenem susceptible A. baumannii (CSAB) infection were assigned to a control group. This retrospective case-control study was based on two groups of patients to determine potential clinical factors contributing to CRAB infection and death among critically ill children via univariate and multivariate analyses.

Results

During the 6-year study period, a total of 372 episodes of nosocomial A. baumannii infection in the PICU were eligible and included in the study. These isolates displayed moderate or high rates of resistance to all tested antimicrobials except colistin. The overall prevalence of CRAB and MDRAB (multidrug-resistant A. baumannii) was 78.0% and 80.9%, respectively. Several risk factors found to significantly increase CRAB infection included receiving invasive operation (OR = 9.412, p = 0.001), gastric intubation (OR = 2.478, p = 0.026), prior carbapenems exposure (OR = 2.543, p = 0.003), severe pneumonia (OR = 3.235, p = 0.001), and hemoglobin <110g/L (OR = 3.049, p = 0.005). Of 372 patients with CRAB infection, the mortality rate was 30.9% (115/372) and mortality did not differ between children with CRAB and CSAB infections. Septic shock (OR = 2.992, p = 0.001), AST > 46U/L (OR = 2.015, p = 0.005), bone marrow aspiration (OR = 2.704, p = 0.008), lymphocyte <20 % (OR = 1.992, p = 0.006) and age (OR = 1.094, p = 0.002) were independent risk factors for the death of A. baumanni infection.

Conclusions

This study highlights considerable incidence rate and remarkable mortality of children with A. baumanni (especially CRAB) infections, and identifies age-specific risk factors for CRAB infection and mortality in critically ill children. These risk factors should be taken into account in pediatric hospitals in order to establish early intervention and rational treatment to improve clinical outcomes.

Bone biopsy devices - a patent review

INTRODUCTION

Bone biopsies have great value for the diagnosis of, amongst others, hematologic diseases. Although the bone biopsy procedure is mostly performed minimally invasive with the use of a slender cannula, the patient may still experience discomfort, especially when the procedure has to be repeated due to an unsuccessful biopsy.

AREAS COVERED

This review presents a comprehensive overview of bone biopsy devices presented in the patent literature. The patents were obtained using a classification search combined with keywords in the Espacenet patent database and were subsequently verified using pre-set eligibility criteria. This resulted in 62 unique patents included in this review.

EXPERT OPINION

The included patents were categorized based on the used strategies for the three steps that can be identified during a bone biopsy (1) biopsy sampling, (2) biopsy severing and (3) biopsy harvesting. Most patents described strategies for multiple steps. Insight into the used strategies and the comprehensive overview may serve as a source of inspiration for the design of novel bone biopsy devices.

Correlations between glucose metabolism of bone marrow on 18 F-fluoro-D-glucose PET/computed tomography and hematopoietic cell populations in autoimmune diseases

PURPOSE

This study aims to investigate which hematopoieticcell populations, clinical factors, and laboratory values are associated with FDG uptake in bone marrow (BM) on FDG PET/CT in patients with autoimmune diseases.

METHODS

Forty-six patients with autoimmune disease who underwent FDG PET/CT and BM aspiration (BMA) between 2017 and 2022 were enrolled. The max and mean standard uptake values (SUVmax and SUVmean, SUVs) of FDG in BM, liver, and spleen were measured, and the bone marrow-to-liver SUVs ratios (BLRmax and BLRmean, BLRs) and spleen-to-liver SUVs ratios (SLRmax and SLRmean, SLRs) were calculated. BMA and clinical and laboratory parameters were collected and evaluated for association with BLRs and SLRs.

RESULTS

The patients were divided into the Grade II group (20; 43.5%) and Grade III groups (26; 56.5%) according to hemopoietic activity. The BLRmax ( P = 0.021), proportion of granulocytes ( P = 0.011), metamyelocytes ( P = 0.009), myelocytes ( P = 0.024), and monocytes ( P = 0.037) in BM were significantly higher in the Grade II group. Multivariate (stepwise) linear regression analyses showed that the proportion of granulocytes in BM was the strongest and only independent factor ( P < 0.0001) associated with BLRmax with an adjusted R2 of 0.431 in model 1. In model 2, ferritin ( P = 0.018), CRP ( P = 0.025), and the proportion of metamyelocytes ( P = 0.043) in BM were correlated with BLRmax with an adjusted R2 of 0.414.

CONCLUSION

The FDG uptake in BM is associated with hemopoietic activity and is regulated by hyperplastic granulocytes, particularly immature metamyelocytes, in patients with autoimmune diseases. Glucose metabolism in the BM correlates with the severity of systemic inflammation.

Synthesis of Microscopic Cell Images Obtained from Bone Marrow Aspirate Smears through Generative Adversarial Networks

Simple Summary

This paper proposes a hybrid generative adversarial networks model—WGAN-GP-AC—to generate synthetic microscopic cell images. We generate the synthetic data for the cell types containing fewer data to obtain a balanced dataset. A balanced dataset would help enhance the classification accuracy of each cell type and help with an easy and quick diagnosis that is critical for leukemia patients. In this work, we combine images from three datasets to form a single concrete dataset with variations of multiple microscopic cell images. We provide experimental results that prove the correlation between the original and our synthetically generated data. We also deliver classification results to showcase that the generated synthetic data can be used for real-life experiments and the advancement of the medical domain.

Abstract

Every year approximately 1.24 million people are diagnosed with blood cancer. While the rate increases each year, the availability of data for each kind of blood cancer remains scarce. It is essential to produce enough data for each blood cell type obtained from bone marrow aspirate smears to diagnose rare types of cancer. Generating data would help easy and quick diagnosis, which are the most critical factors in cancer. Generative adversarial networks (GAN) are the latest emerging framework for generating synthetic images and time-series data. This paper takes microscopic cell images, preprocesses them, and uses a hybrid GAN architecture to generate synthetic images of the cell types containing fewer data. We prepared a single dataset with expert intervention by combining images from three different sources. The final dataset consists of 12 cell types and has 33,177 microscopic cell images. We use the discriminator architecture of auxiliary classifier GAN (AC-GAN) and combine it with the Wasserstein GAN with gradient penalty model (WGAN-GP). We name our model as WGAN-GP-AC. The discriminator in our proposed model works to identify real and generated images and classify every image with a cell type. We provide experimental results demonstrating that our proposed model performs better than existing individual and hybrid GAN models in generating microscopic cell images. We use the generated synthetic data with classification models, and the results prove that the classification rate increases significantly. Classification models achieved 0.95 precision and 0.96 recall value for synthetic data, which is higher than the original, augmented, or combined datasets.